Provider Demographics
NPI:1669569307
Name:MATHENY, CHARLES ANDREW TILMAN (PA-C)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:ANDREW TILMAN
Last Name:MATHENY
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:1825 MARTHA BERRY BLVD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1625
Practice Address - Country:US
Practice Address - Phone:706-295-5331
Practice Address - Fax:706-238-8011
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2020-04-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA004873363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA514162077AMedicaid
GA97WCHZJMedicare ID - Type Unspecified